Provider Demographics
NPI:1669667937
Name:OWEN HILEY, PAMELA (LPN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:OWEN HILEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 1/2 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2051
Mailing Address - Country:US
Mailing Address - Phone:920-791-0930
Mailing Address - Fax:
Practice Address - Street 1:109 1/2 4TH ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2051
Practice Address - Country:US
Practice Address - Phone:920-791-0930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32178-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38279700Medicaid